. celebrating cultural identity

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FEMALE GENITAL MUTILATION

A HANDBOOK FOR FRONTLIME WORKERS

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TABLE OF CONTENTS

Finding the right messages ... 54

ACKNOWLEDGMENTS ... INTRODUCTION

...

Well-planned strategies and tailored activities ... 58

Working with the mass media ... 61

PART 1: WHO IS AFFECTED BY FGM? High quality training for all ... FGM IN THE WORLD TODAY

...

9 111: MEASURES OF PROGRESS

...

Definitions and classifications of FGM ... 10

A vital role for research ... How is FGM carried out? ... 10

Finding out what works best ... Measuring the impact of programmes ... 74

PART 2: WHY DO PEOPLE PRACTISE FGM? THE SOCIAL CONTEXT

... ...

13 CASE STUDIES: SOME SUCCESSFUL PROJECTS The "mental mapn ... 14

EGYPT: Communities monitor "at risk" girls ... 81

What the research tells us ... 15

. .

^KENYA: Communities celebrate alternative Nlgerla ... 15

coming of age ceremonies ... 83

Somalia ... ... 16

SENEGAL: Empowerment of women leads Sudan ... ... 17 to ban on FGM . the TOSTAN experience . . . 87

Egypt ... ... 18

UGANDA: The REACH Programme . celebrating cultural identity ... PART 3: THE HEALTH CONSEQUENCES OF FGM A DANGEROUS PRACTICE

...

23 COMMENTS AND RECOMMENDATIONS What the research tells us ... Immediate complications ... Long-term complications ... ... 23

COMMENTS AND RECOMMENDATIONS

...

9 5 ... 23

LIST OF ACRONYMS

...

97

... 25

Problems in pregnancy and childbirth ... 28

ANNEXES: Psychological and sexual consequences of FGM . . 29

1

.

International action ... PART 4: FGM PREVENTION PROGRAMMES: LESSONS FROM THE FIELD I: STRONG FOUNDATIONS

...

35 HIGHLIGHTED TEXT

...

Players in the field ... 35 'Itvo women tell their stories ... Laws and policies to protect women and girls ... 37 The Inter-Africa Committee on Harmful ... Making FGM a mainstream issue 40 Traditional Practices at work in Burkina Faso Training for health care providers ... 41 and Ethiopia ... 36

... ... Coordination between anti-FGM organizations 42 FGM and the law 38 .... .. -p- A central role for advocacy ... 43 To pass a law or not to pass a law? ... 39

A physician speaks out ... 41

Egypt's "New Horizonsn Project ... 50

The dangers of focusing on FGM as a 11: COMMUNICATION AND BEHAVIOUR CHANGE

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4 6 A role for all players ... 48

A focus on youth

... ...

⁴⁹

health issue ...

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A focus on human rights in Egypt A focus on urban elites ... Mali fosters community decision-making A limited role for traditional excisors ... 51 over FGM ...

Building on positive community values ... 52 Some pitfalls to avoid

...

Please click inside the blue boxes below to access the chapters within.

FEMALE GENITAL MUTILATION

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A HANDBOOK FOR FROMTLINE WORKERS

ACKNOWLEDGMENTS

The World Health Organization (WHO) wishes to thank the following teams and collaborating institutions and organizations for the reviews on:

(a) FGM programmes: Asha A. Mohamud, Nancy A. Ali and Nancy Yinger (Program for Appropriate Technology in Health (PATH);

(b) socio-economic and cultural aspects: Dr Rhetta Moran, Dr Hermione Lovel, MS Zeinab Mohammed (University of Manchester) and Dr Margaret Njikam Savage (University of Douala); and

(c) on the health complications: Dr Hermione Lovel, Dr Claire McGettigan, MS Zeinab Mohammed (University of Manchester)

WHO gratefully acknowledges the support provided by the WHO Regional and Country Offices for the Eastern Mediterranean and Africa, the many individuals and the network of researchers in countries who contributed to the reviews.

WHO also gratefully acknowledges the financial support of AUSaid, DFID and UNFIP for the project.

Acknowledgments to Efua Dorkenoo, Department of Women' ^S Health, WHO for initiating the project, coordinating key technical inputs into all the reviews and bringing together the information into one document.

Thanks goes to Jillian Albertolli for administrative support. Special thanks also go to Sue Armstrong for editing of the handbook.

Design: Mr Caleb Rutherford - eidetic Photos: WHO

O World Health Organization, 2000

This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes.

The views expressed in documents by named authors are solely the responsibility of those authors.

Department of Women's Health Family and Community Health World Health Organization

Geneva

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INTRODUCTION

Until relatively recently, scientists, the international organizations asking for information on their anti- community and national governments turned a blind FGM programme strategies and activities, staffing, eye towards female genital mutilation (FGM), sources of funds, target audiences, materials unwilling to tackle an issue of such extreme sensitivity. developed, evaluation, difficulties experienced and The few people who did try to investigate and

challenge the practice met with such a strong and hostile reaction from communities where FGM was the tradition that most quickly dropped the matter.

lessons learnt. 102 questionnaires were returned, and the information from 88 organizations particularly active in the field was analysed in depth. Subsequently, PATH researchers visited five African countries with However, a number of concerned individuals and strong programmes. These were Burkina Faso, Egypt, organisations persisted with their challenge, and their Ethiopia, Mali and Uganda. In addition to the country tireless advocacy has borne fruit. Today, there is wide visits, the researchers looked in depth at specific recognition at global and national levels of the harmful projects in Kenya and Senegal.

effects of FGM and of the pressing need for systematic action to accelerate the elimination of the practice.

Over the past two decades, FGM prevention

Aware of the fact that the elimination effort is hampered by major gaps in understanding why communities practise FGM and what effects the programmes have been established in most countries different types have on health, WHO also where this is practised. They are working today at the commissioned literature reviews of the social, level of policies and laws as well as at the grassroots

among communities where FGM is the tradition.

economic and cultural context of FGMZ, and its health consequences3 from teams at Manchester University.

What strategies have these programmes used? What The purpose of this handbook is to share with have been their strengths and weaknesses? And what readers the key findings of these research projects. The have they learnt from experience that would be useful aim is to increase the effectiveness of prevention to others in the field? In order to answer these campaigns at all levels by increasing understanding of questions and to identify the actions and ideas that the practice, and by identifying what does and does not should be given priority support, the World Health work in the field and why. The handbook is intended Organization (WHO) commissioned the Program for primarily for non-governmental organizations (NGOs) Appropriate Technology in Health (PATH) to carry out committed to the elimination of FGM, and for others a review1 of anti-FGM programmes operating mostly working at the frontline with communities that practise in countries in Africa.

The review consisted of a detailed questionnaire sent out to 365 national and international

it, for example health service personnel. But it should

be of interest, also, to those responsible for policy- making in this field at national and international levels.

'

"Female Genital Mutilation. Programmes to date: what works and what doesn't. A review': The original report, ref. WHOICHSIWMH199.5, can be obtained from the Department of Women's Health at WHO, Geneva.

''!A framework for the analysis and collation of primary data on the sodo-economic-cultural aspects of female genital mutilation".

(Unpublished report), Department of Women's Health, WHO, Geneva.

' "A systematic review of research on health complications following female genital mutilation including sequelae in childbirth", The original

report, ref. WHO/FCH/WMH/OO.Z, can be obtained from the Department of Women's Health at WHO, Geneva.

FEMALE GENITAL MUTILATION

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A HAND.ooK m FRONT,,.. ,EM,

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The handbook is divided into four parts:

Part 1 discusses what is known about the extent of FGM and where it is practised today:

Part 2 looks at the attitudes and beliefs that underpin FGM;

Part 3 looks at the health consequences associated with the different types of FGM;

Part 4 describes existing anti-FGM programmes in selected countries, their activities, strengths and weaknesses, and discusses lessons learnt.

The handbook is presented in such a way that the different sections or subject areas can be used separately, if desired, for reference, or teaching purposes, or photocopying.

FOREWORD

100-140 million women and girls are estimated to have undergone some form of female genital mutilation (FGM). FGM can have serious health consequences and is of great concern to the World Health

Organization (WHO). In addition to causing pain and suffering, it is a violation of internationally accepted human rights. WHO'S governing bodies have adopted a number of resolutions urging Member States to establish clear national policies to end traditional practices that are harmful to the health of women and children and have requested that WHO strengthen its technical support and other assistance to the countries directly concerned.

WHO has consistently and unequivocally advised that female genital mutilation, in any of its forms, should not be practised by any health professional in any setting, including hospitals or other health establishments.

Although much has been achieved over the past two decades in lifting the veil of secrecy surrounding FGM, the elimination effort continues to be hampered by lack of information. There are still major gaps in knowledge about the extent and nature of the problem and the kinds of interventions that can be successful in eliminating it. Moreover, although there is a growing body of data on the physical consequences, little sound research has been conducted on the psychological effects

on c h i i e n , on the psychosexual impact on women, or on how to care for those who experience these problems.

Notwithstanding the limitations posed by gaps in existing knowledge, FGM prevention programmes have been established over the past two decades in most countries where it is practised. Anti-FGM campaigners have been working to change policies and laws, as well as at the grassroots level among communities where FGM is the tradition. What strategies have these programmes used? What have been their strengths and weaknesses ? And what have we learned from experience that would be useful to others in the field? What do the available research data tell us about the reasons why communities practise FGM, and the effects the different types of FGM have on the health of women and girls?

This handbook, which addresses these questions, is dedicated to the millions of women and girls who have undergone FGM and who continue to suffer the consequences of this practice. The authors have carefully reviewed research that will be useful to health professionals, non-governmental organizations and policy makers in advocating for technically sound policies and approaches to discourage this practice. It is hoped that lessons learned from the research findings will help to increase the effectiveness of the current effort to eliminate FGM.

Dr Olive Shisana Executive Director Family and Community Health

World Health Organization

FEMALE GENITAL MUTILATION

A HANDBOOK FOR FRON.,NE wwms

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FGM IN THE WORLD TODAY

Because of the sensitivity of the issue, comprehensive data on the numbers of girls and women affected by FGM in different countries are extremely scarce and vary greatly in quality and reliability. Sudan was the first country, in 1979, to undertake a systematic nationwide survey of the practice, and is the only country able to provide comprehensive and reliable data over time. More recently, Ivory Coast, Central African Republic, Egypt, Eritrea, and Mali have used their National Demographic and Health Surveys to gather information on FGM. A module has been developed for this purpose and it is hoped other

countries will adopt it also to generate reliable figures.

On the basis of available information it is estimated that 100 - 140 million girls and women have undergone some form of female genital mutilation. It is also estimated that each year a further 2 million girls are at risk from the practice. Most of the females affected live in 28 Afiican countries, and a few in the Middle East

and Asia. Today, however, increasing numbers of girls and women who have suffered FGM can be found in

Europe, Australia, New Zealand, Canada and the United States of America, mostly among immigrants from countries where FGM is the tradition.

Current estimates of female genital mutilation in Africa

I country Female Prevalenceb Number Country Female Prevalenceb Number

I populationa population'

I

Benin Burkina Faso Cameroon

Central African Rep.

Chad Cote dlvoire Democratic Republic

of the Congo Djibouti EgY Pt Eritrea Ethiopia Gambia Ghana Guinea Guinea-Bissau

Kenya Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Somalia Sudan Togo Uganda United Republic

of Tanzania

The world's women. New York, NY, United Nations, 1995 (37).

Prevalence expressed as a percentage. Prevalences for Central African Republic, CBte d'Ivoire, Egypt, Mali and Sudan from Demographic and Health Survey results.

Worldpoputation prospects: the 1994 revision. New York, NY, United Nations, 1994 (38).

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Definition and classifications of FGM (WHO, 1995)

Female genital mutilation constitutes all procedures which involve the partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or any other non- therapeutic reasons.

Type I: Excision of the prepuce with or without excision of part or all of the clitoris.

Type 11: Excision of the prepuce and clitoris together

with partial or total excision of the labia rninora.

Type 111: Excision of part or all of the external genitalia and stitchingtnarrowing of the vaginal opening (infibulation)

Type IV: Unclassified: Includes pricking, piercing or incision of the clitoris andlor labia; stretching of

the clitoris andlor labia; cauterization by burning of the clitoris and surrounding tissues; scraping

(angurya cuts) of the vaginal orifice or cutting (gishiri cuts) of the vagina; introduction of corrosive substances into the vagina to cause bleeding, or herbs into the vagina with the aim of tightening or narrowing the vagina; any other procedure which falls under the definition of FGM given above.

How is FGM carried out?

,

c1ssors, FGM is carried out using special knives s ^' razors, or pieces of glass. The operation is usually performed by an elderly woman of the village specially designated this task, or by a traditional birth attendant (TBA). Anaesthetics are rarely used and the girl is held down by a number of women, frequently including her own relatives. The procedure typically takes 15 to 20 minutes, depending on the skill of the operator and the amount of resistance put up by the girl. The wound is dabbed with anything from alcohol or lemon juice to

ash, herb mixtures, porridge or cow dung, and the girl's legs may be bound together until it has healed.

In some countries, more affluent families seek the services of medical personnel in an attempt to avoid the dangers of unskilled operations performed in insanitary conditions. However, the medicalization of FGM, which is willful damage to healthy organs for non-therapeutic reasons, is unethical and has been

consistently condemned by WHO.

The age at which girls are subjected to FGM varies enormously, and is often flexible even within

communities, either because it is not tied to any particular ceremony, or because people's belief in its ceremonial significance has died away. The procedure may be carried out when the girl is newborn, during childhood, adolescence, at the time of marriage or during her first pregnancy. In some cultures, a woman is re-infibulated (re-stitched) following childbirth as a matter of routine.

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THE SOCIAL CONTEXT

The "mental map"

The origins of FGM are impossible to establish, though it is known from archeological evidence to be centuries old. Moreoever, it has been practised in some form by the natives of every continent at some point in time.

In communities where FGM is the tradition, the practice is so deeply rooted in the social fabric that few people question where it started or why. It is supported by a whole range of beliefs, values, myths, superstitions and codes of behaviour that reinforce one another and are integral parts of the "mental map" people use to guide them through life. This mental map gives individ-

uals an idea of where they stand in relation to others; it draws the boundaries between men and women, young

people and old, and directs their behaviour towards each other. Everyone carries a mental map that serves these purposes, and people of the same culture generally have similar mental maps. However, these are not fixed:

they vary and change over time under the influence of education, life experiences, contact with other cultures, exposure to the media, and other such forces.

The mental maps of people who practise FGM present them with powerful reasons why the clitoris and other external genitalia of girls and women should be removed. At the core of the map are the religious, sociological, hygienic and aesthetic reasons. According to these, a woman's external genitals are ugly and dirty, and will continue to grow ever bigger if they are not cut away. They are believed to make women spiritually

unclean. And some people believe that unless her clitoris is removed, a girl will not become a mature woman - or even perhaps a full member of the human race. Among the myths associated with FGM is the belief that a woman's external genitals have the power to

blind anyone assisting her in childbirth, to cause the death of her baby or else physical deformity or madness;

and to cause the death of husbands and fathers.

Psycho-sexual reasons for FGM focus on the ill effects that will be suffered by the girl, her family, potential husbands and society in general if her external genitals are not removed. The unexcised girl is believed to have an over-active and uncontrollable sex drive so that she is likely to lose her virginity

prematurely, to disgrace her family and damage her chances of marriage, and to become a menace to all men and to her community as a whole.

In addition to the range of beliefs and perceptions that support FGM, women and girls are subjected to powerful social pressures to ensure they continue the practice. Typically, women who are not excised are considered unsuitable for marriage. A woman

discovered to be unexcised at the time of her marriage may face immediate divorce, or forcible excision.

When their turn comes for excision, girls may be sworn to secrecy so that the horror and pain of the experience are not discussed with others, especially unexcised women. Moreover, girls who are unexcised are often stigmatised. They may be jeered at as being unclean and smelly, ridiculed in songs and poems, threatened with punishment by God, or told they will provoke the wrath of their ancestors and other spirits While the overall mental map is similar in most of the countries that practise FGM, some reasons are more prominent in certain countries than others. For

example, some Muslim countries tend to associate the practice with tradition as well as with Islam. In some societies, the emphasis is on the "rite of passage" - or transition - from childhood to adulthood. In others, the mythological aspects are considered most significant.

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WHY THE PRACTICE OF FGM CONTINUES:

THE MENTAL MAP

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The temptation for anti-FGM programmes to simplify matters, and to address individual aspects of the mental map rather than the whole picture, is strong. But it is also a root cause of failure to stop the practice. In the real world, the different elements of the mental map that support FGM are interwoven and mutually reinforcing; efforts to tackle them singly lack credibility with those who have experienced andlor support FGM. Thus the task of prevention

programmes must be to try to understand and dismantle the mental map in its entirety. This is a painstaking task, for there is a dire shortage of reliable information to start off with.

What the research tells us

The research study on the social, economic and cultural aspects of FGM undertaken by the Manchester University team began with a search through the social science literature for primary data - that is, first-hand

accounts of FGM, focusing on its social context. In the short period of the project, the team identified only 40 such studies, a few of which dated from the 1930s, and one from 1847. The range of issues covered by the studies is limited, with information on economic influences, and on sexual relationships and FGM, being particularly scarce.

The team devised a model table for recording the information given in the studies so that it can be easily extracted and compared with other such studies. The countries that figure most prominently in the

literature are Nigeria, Somalia, Sudan, and, to a lesser extent, Egypt. Despite the limited scope and

geographical spread of these studies, they offer insights into the mental maps of communities that practise FGM, and how time and other influences may alter the picture, that are widely relevant.

Nigeria

Eight of the 40 studies focus on Nigeria, and all

note marked tribal difference in the customs and beliefs related to FGM. They show that parents are the most important decision makers regarding excision for the girls of the household. Whether the primary decision maker is the mother, the father, or both parents equally, depends greatly on the tribe they belong to. Education level appears to influence the decision, with one study from 1987, in which 2300 respondents were asked whether or not they were in favour of excision for their daughters, finding the following:

% Yes % No % Don,

V - -. . .

illiterate

(1403 people) primary education

(537 people) 53.6 6.9 39.5

- - -

secondary education

(360 people) 60.5 25.5 14.0

A more recent study involving 1025 mothers, 99%

of whom had been excised, found that those who had secondary level education were more likely to have refused FGM for their own daughters than those with less schooling. In this study too, the daughters o f urban women were less likely to have been excised than rural girls, regardless of the education levels of their mothers, suggesting that city life had an influence on attitudes. However, the rate of FGM was still high among all groups - ranging from 98% of the rural girls to 87% of girls from urban families whose mothers were well educated.

In many of the studies, "tradition" was given as the dominant reason for practising FGM. Some people believed that flouting tradition might provoke the ancestors; others that it would leave a woman vulnerable to witchcraft during childbirth, and most said that an unexcised woman would be socially stigmatised. The research revealed that within a

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community practising FGM, there is likely to be a wide range of beliefs - some held by just a few people, some by the majority. For example, among people of the Yoruba tribe questioned in the studies a few

individuals claimed that FGM was necessary to prevent the clitoris growing; others that it was necessary to prevent infection of the clitoris, enhance the

cleanliness of the vagina, curb the sexual promiscuity of women, enhance reproduction, andlor ease childbirth. Many believed that FGM was necessary to protect the life of the baby during birth, though this belief was strongest among rural women - again suggesting the influence of city life on attitudes and beliefs.

A study among rural people of the Uruan tribe found that two thirds of the 400 respondents believed that an unexcised woman posed a threat to her baby - that if the baby's head touched her clitoris during delivery it would die. One third of respondents in the same community, however, did not hold this belief.

Interestingly, all the people questioned were, or had been, traditional birth attendants (TBAs) or midwives.

In this same study, around two thirds of the people questioned saw FGM as a rite of passage into

womanhood, while a third of the people did not attach this significance to it.

Another study, among the Yoruba, found that FGM, once part of a ritual that included ceremonies and camps for young girls about to be excised, had changed dramatically in modem times. The ceremonial aspects had largely died away and girls were most often being excised a few days after birth, rather than as teenagers on the threshold of womanhood. The author of the study suggested that the reason for this was that FGM had become increasingly controversial, and parents and excisors were keen to avoid having to negotiate with teenagers, and chose instead to make unilateral decisions about the procedure when girls were

newborn. The timing of the operation seems to have been flexible in nearly all the communities studied.

Though adolescence was often the preferred time, in reality, girls could be excised at any age from a few days old to 20 years or more.

Somalia

The studies from Somalia span sixty years, from 1932 to 1992. They show that FGM is deeply rooted in tradition, though a sizeable proportion of the people do not perceive it as "positive culture" despite their support for it. The great majority of women are

subjected to the severest form of FGM, type 111.

The data indicate that the predominant reason for the practice is to protect the virginity of women until they are married, at which time in many communities the husband will make some public display of his possession of her, such as carrying around the little knife used to open her scarred vagina, or waving a bloody cloth after consummation of the marriage.

Other reasons given for the practice include the necessity to control women's excessive sexuality, and to enhance health, beauty and cleanliness.

The practice is strongly associated with the rite of passage to adulthood, with many people believing that the unexcised woman is caught in a state of perpetual

immaturity. As such, she is unable to marry and have children - the only paths to social status and

acceptance for many Somali women, especially those who are poorly educated. A 1991 study suggests that the genitalia of an excised woman are such a powerful symbol of her status as an adult, and so closely tied up with her own sense of identity, that many women

cannot imagine being able to dispense with the practice. Unexcised girls are mocked by their peers.

However, there is evidence from a number of other studies that people are prepared to question the value of FGM and to challenge the status quo. A 1986 survey

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among medical students in Mogadishu, for example, found that more than one quarter of the males favoured the less extreme forms of FGM, types I and 11, for their daughters. Less than half expressed the view that the practice should be maintained into the future, though some were concerned their families would oppose marriage to an unexcised girl. Female medical students were even more ready to modify or discontinue the practice. The same study, however, found very different views among female nursing students, who were also interviewed. 95% of them said they would have their daughters excised, and 40% of them would choose type 111. Their views were

considered particularly important since, as nurses, they may well be called upon to perform the operations once they had finished their studies. By contrast, a 1991 study among largely uneducated women found that, whereas two thirds of them had experienced type I11 themselves, less than half would want the severest form of FGM for their own daughters. The studies did not draw any conclusions about the influence of education or city life on people's views or behaviour.

Sudan

The twelve studies from Sudan also span a half century, from 1943 to 1994. As in Nigeria and Somalia,

"traditionn is the most common reason given for FGM.

It is seen as a mark of ethnic superiority by some tribes; though the studies suggest that in Sudan, too, there are many who do not consider FGM to be "good traditionxther important reasons frequently given are that it is required by religion, or necessary for cleanliness, and to preserve the chastity of girls on which the family honour depends.

However, there is evidence of attitudes and beliefs

changing with time. A 1994 study among high school teachers found that 47 out of the 80 women

interviewed said they did not want excision for their

daughters, and nearly 70% said they did not believe in the practice. Of the 32 women who wanted FGM for their daughters, only a very small minority cited tradition as the main reason. Nearly a quarter believed it was required by their Muslim religion, and a quarter favoured it for reasons of hygiene. Of the minority who supported the practice, many had been re- infibulated following childbirth as a matter of routine.

They perceived virginity to be a renewable condition, and re-infibulation to be necessary for this purpose and for the sexual pleasure of their husbands.

Opinions were divided on this issue: while most of the women who favoured re-infibulation claimed that it enhanced their own enjoyment of sex as well as that of their husbands, very many women rejected re-

infibulation because they felt it impaired their own sexual pleasure. Despite the still strong support for FGM from a minority of her sample, the author concluded from her study that education,

urbanisation, and the changing roles of the family were eroding the influence of the older generation of women in the decision making process regarding FGM. Educated daughters were increasingly able to make up their own minds.

However an earlier study ( 1978) among 185 male and female students at the University of Omdurman showed how uneven and unpredictable these

influences can be. All the women had experienced type I11 FGM themselves, and 91% of them supported continuation of the practice, and favoured the severest form for their future daughters as well. All respected it as a traditional part of their culture, nearly half believed it was required by their religion, one third that it was necessary for hygienic reasons, and many that it ensured a girl's chastity. In stark contrast, 86%

of their male peers were against all forms of FGM, believing it was an old fashioned custom, that it spoilt women's and men's sexual pleasure, and that it was

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cruel, barbarous and dangerous. Only one of the calm their fears. Some tribes ceremonially bury the women expressed these damning views of the practice. excised flesh to ward off harm, while others take girls

Interestingly, in spite of the clear opposition to FGM to the river at sunset for rituals aimed at protecting expressed by the great majority of their male peers, them from infection, bleeding and other dangers nearly all the female students believed that a woman associated with FGM. Complications suffered at the who was unexcised was unmarriageable. Clearly, this time of excision may be treated with traditional cures, was a more important consideration than any of the such as the inhalation of smoke from burning paper new ideas they had encountered at university. inscribed with texts from the Koran. The various

The significance of FGM to marriage and a girl's practices described here and in other studies

perceived value as a bride is underlined by a large demonstrate how supporters of FGM often cope with study from 1982. The author found that, in some the harmful effects of FGM by developing myths and communities, girls with a particularly narrow vaginal rituals to explain and treat them, rather than seeing opening, suggesting special virtue, commanded a them simply as unnecessary evil and a good reason for higher bride price than those with less severe FGM. In giving up the practice. However, more recent studies cases where the opening was too tight to enable suggest that in some communities the ceremonial penetration by her husband's penis on her wedding practices are diminishing and FGM is being performed night, the bride would sometimes be given "honour more and more often without celebration or ritual.

money" by her bridegroom in recognition of her While most studies provide evidence that

virtue, and it would be a source of pride to her family. influences such as education and city life are tending, According to a 1991 study, however, bride price is gradually, to undermine support for FGM, two show

becoming an increasingly heavy burden on families, how they can sometimes have the opposite effect. They and in some places communities have agreed, through describe how girls and women from non-practising

group discussion, to put limits to the price. tribes, such as the Nuba and Fur, who are now living in towns and villages among people who do practise

FGM, are sometimes choosing to have

A 1991 study among rural women from Sudan found that the operation themselves. Most are virginity was an absolute requirement for marriage, and doing so because they look up to the virginity was synonymous with infibulation, or type Ill FGM. tribes that practise FGM and see it as a In this belief system, the hymen had no significance. status symbol. But some do so to save

themselves from the ridicule and jeering of neighbours who are excised.

Several studies describe the rituals surrounding

FGM, which typically includes new clothes, jewellery

Egypt

and henna decorations for the girl to be excised, and A study from Egypt, dated 1995, gives data the giving of gifts during several days of celebration. In gathered over a ten Year period from 85 women aged some communities, girls terrified at the prospect of the 15-70 Years, 21 of whom were excis0i-s. There were operation are taken to traditional healers, who use the about equal numbers from the rural areas and from smoke of special herbs, sacred water, or amulets to the cities; half were illiterate, while one in seven had 8

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years or more of schooling; the great majority were Muslims; all were married and they had all

experienced FGM, mostly types I and 11.

The study found a widely held belief that the clitoris is responsible for a woman's sexual appetite and that it continues to grow unless it is removed, thus threatening to overwhelm a husband's sexual capacity and

dangerously sap his physical strength. Some believed the unexcised clitoris could grow to a size that would interfere with a man's pleasure during intercourse. Most women knew that FGM is not required by the Koran, and religion was rarely mentioned as a reason for the practice. Everyone interviewed expressed the view that it was necessary to protect a girl's virginity, and her family's honour, until the time of her marriage. Some also believed FGM influenced a girl's behaviour, making her demure and submissive in public, and therefore a credit to her family.

The majority of women were excised between the ages of 9 and 13 years, usually during national or religious holidays. Typically they were not prepared mentally for the operation, and in more than half the cases they were held by their mothers while it was

performed by a traditional excisor using a razor. There is no mention of celebration. Interestingly, the author notes that FGM is far more common among the urban elite than is generally assumed.

Another study from Egypt, dated 1980, gives an indication of how many people might be involved in the decision to excise a girl child. The researchers interviewed women and men attending a family planning clinic over a one week period. They

discovered that in one case, where the mother of a girl was unexcised, the father's sister had taken the decision for the daughters. In another case, the parents and brothers of the girl had decided. In a third case, the mother, together with maternal and paternal aunts, had made the decision. And in a fourth case, an aunt who had been excised herself took the decision for her two nieces without their mother's consent.

Questioned about their attitudes to FGM, about ten percent of the sample said it was necessary for cleanliness. One man said he preferred a woman who was clean and psychologically calm; and one woman said she believed FGM made girls taller, prettier and clearer skinned.

FEMALE GENITAL MUTILAT!ON

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A HANDBOOK FOR FRONTLINE hORKERS

l

KEY POINTS

The rationale for supporting FGM -the m FGM is often a powerful symbol of ethnic mental map

-

must be understood and identity, and sometimes a status symbol.

addressed in its entirety, not broken down

into separate issues. The girl who rejects FGM may be perceived by her own family as bringing them dishonour The mental map is not fixed, but changes and showing disrespect for her elders.

constantly under the influences of modern

lifestyles and ideas. m Even within a community that practises FGM there is likely to be a range of

In communities where women have little or attitudes and beliefs, some of which may be no opportunity for economic independence, contradictory. Therefore, anti-FGM

marriage is virtually the only means of messages based on generalisations will not survival. The girl who rejects excision may be credible t o everyone.

forfeit her chances of marriage.

m Practising communities have their own,

A girl's excision often has economic often mystical, ways of explaining and

implications for her family, ie. in securing coping with the harm associated with FGM, and determining the size of the bride price. so new information is not being received in Sometimes this is critical t o the family's a vacuum.

survival.

In some communities virginity, which is

Not only the girl, but her whole family may highly prized, is considered t o be a risk stigmatisation and social isolation if she renewable condition and women are re- does not conform t o the community's stitched after childbirth as a matter of

customs. routine.

1

I

^{FEMALE GENITAL} MUTILATIOIW w w m o o K FOR F R o N n r N E w o w a s

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A DANGEROUS PRACTICE

Female Genital Mutilation causes grave and deliberate complications identified by the papers, which span a damage to children and women. Because few records period from the 1920s to the present day, include:

are kept and the practice is shrouded in secrecy, no one

knows how many females die as a result, though immediate problems following FGM

mortality of girls at the time of initiation is probably gynaecological and obstetric problems, including high. The range of complications associated with FGM

is wide and some are severely disabling. Here too the urinary problems

picture is incomplete, and no one knows what sexual and psychological problems.

proportion of women suffer complications. However, it is important to remember that not all women will have personal experience of any particular health problem, or combination of problems. Information campaigns that focus on health issues risk losing credibility with their target audiences unless this is acknowledged, and complications put into some kind of perspective. For example, the timing of the

procedure - that is, whether it is carried out in infancy, childhood, adolescence or during pregnancy - has an influence on the outcome. Other important factors determining the outcome of an operation include the extent of the cutting, the skill of the operator, the cleanliness of the environment and tools used, and the physical condition of the child.

What the research tells us

The main purpose of the WHO-sponsored research project into the health consequences of FGM was to review the primary data on complications to give an idea of how frequently they occur and who is most at risk. The project team found a total of 474 papers and reports which they considered relevant to their enquiry. 138 of these contained first hand information on health consequences. The others were review articles, documents with background information, or foreign language material still to be classified. Health

However, it is impossible to draw any firm conclusions about what proportion of girls and women subjected to FGM experience complications, or about who is most likely to suffer from what and why. The information is just too limited: Many complications go unreported, so health service records that appear in the primary data are not representative.

When questioned by researchers, women may b e reluctant to admit complications. Or they may be

unaware that the problems they suffer are the result of FGM, attributing them instead to some other, perhaps

supernatural, cause. As with the previous section, reference to the findings of the research project offers only valuable insights, not the basis for conclusions or generalisations.

Immediate complications

Haemorrhage.

Amputation of the clitoris cuts across the clitoral artery in which blood flows at high pressure. Cutting of the labia also damages arteries and veins. Not surprisingly, severe bleeding (haemorrhage) is one of the most common immediate complications of excision. Haemorrhage may also occur after the first week as a result of the crust that has formed over the wound sloughmg off, usually because of infection.

FEMALE GENITAL MUTILATION

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A study of FGM in Sudan, published in 1982, found that haemorrhage accounted for nearly one quarter of reported complications. Although it should be noted that one in four of the total sample, which involved women from five of the six provinces of northern Sudan, suffered no immediate complications of FGM. A 1980 study in the same country found that

17 girls of a sample of 7505 (0.2%) who had been excised suffered severe haemorrhage as an immediate consequence. In the great majority of cases the operation performed was type 111. In some, the excisor was unable to stop the bleeding and the girl went into shock as a result of blood loss as well as pain. In a Nigerian study analysing hospital records between

1973-81, two out of a sample of 55 children (or 3.6%) brought to the paediatric clinic with complications of FGM involving the amputation of the clitoris suffered severe bleeding. In Somalia, 20% of a sample of 300 women interviewed by researchers in 1995 said they had suffered haemorrhage at the time of excision.

Shock.

Immediately after the operation the child may enter a state of shock as a result of haemorrhage, or else from the pain and anguish of the procedure since most operations are performed without anaesthetic.

Shock, which can be fatal, is rarely mentioned in the literature on health consequences. However, the Sudanese study cited above found that 3 1 of the 790 girls with immediate complications of FGM suffered from this condition. All had experienced the most extreme form of FGM, type I11

Infection.

Infection, due to unhygienic conditions and the use of unsterilised instruments or crude tools, is common.

Infection may also be caused by the use of traditional medicines on the wound, and encouraged by the

practice of binding the girl's legs together which prevents drainage. Tetanus occurs when spores get into the wound from unsterile instruments or

contamination with faeces, and is almost always fatal.

Sometimes infection becomes generalised, leading to potentially fatal blood poisoning (septicaemia), or gangrene, which is death of surrounding tissue.

In the Nigerian study already mentioned, four of the 55 children brought to the paediatric clinic with complications of FGM were suffering from infection.

One had septicaemia, another had tetanus and the other two had urinary infections. A study in Benin, from 1977, describes a woman brought into hospital as an emergency with septicaemia following FGM performed in the thirty-ninth week of pregnancy. Her baby was delivered by caesarian section, but died two days later from the infection, and the mother also died, on the fifth day following delivery from septicaemia. In a similar case from Nigeria where a woman excised during the thirty-fourth week of pregnancy was admitted to hospital as an emergency because of severe bleeding and infection, the baby was stillborn. Of the 300 women interviewed in the 1995 study in Somalia already cited, 60% said their wounds had become infected. In the Sudanese survey already mentioned, infection accounted for 151 of the 790 immediate complications of excision. In this study, infection of the wound was about ten times more common in girls with type I11 FGM than with type 11.

Urine retention.

Pain, swelling and inflammation around the wound, or injury to the urethra, can make it difficult or impossible for the girl to pass urine for hours, and sometimes days, following FGM. The frequency with which this complication occurs varies according to the type of procedure. It often leads to infection of the urinary tract.

FEMALE GENITAL MUTILATION A HANDBOOK FRONnINE WORKERS

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A study involving 7505 women in Khartoum, Sudan, found that urine retention was the most common immediate complication of excision,

affecting 12% of the women. The great majority had undergone the severest form of FGM, type 111. Urine retention accounted for 84 of the 790 immediate complications of excision in the other large Sudanese study. 75 cases were in girls with type I11 FGM, 17 with

type I1 and 2 with type I. 172 of the 790 girls had difficulty passing urine, because of the pain and burning sensation in the raw wound, or because the opening was constricted by stitching or swelling.

Injury to neighbouring organs.

As a result of careless techniques with crude tools, failing eyesight, poor light or the struggles of the girl, organs such as the urethra, vagina, perineum or rectum may be damaged. This can lead to the

formation of fistulae, which are false passages between the vagina and the bladder or the vagina and the rectum, through which urine or faeces leak continuously.

Long-term complications

Bleeding.

Bleeding can occur some time after the operation if the wound becomes infected. Repeated de-infibulation

(opening up the vulva to allow sexual intercourse or childbirth) and re-infibulation (re-stitching following childbirth) may also cause the loss of blood which

may, over the long-term, lead to anaemia.

In one study from Sudan involving 934 patients

with FGM complications at a Khartoum hospital, 4.4%

sought medical attention because of severe bleeding as a result of sexual intercourse. Some of the 41 cases

required resuscitation. A 1997 study from Ghana involving 195 women attending a rural antenatal clinic over a two day period found that 9 of the 76 women

who had FGM (typically type I or 11) suffered persistent bleeding after sexual intercourse. None of the 119 women without FGM had this complaint.

Furthermore, of the women with FGM, 26% had suffered lacerations andlor haemorrhage during the birth of their first babies. No information is given for those without FGM. Three quarters of the women with FGM had been excised in early childhood. The others had been excised as adolescents or young adults.

Difficulty in passing urine.

The urinary opening or urinary canal may b e damaged during genital mutilation or subsequent infection, resulting in difficulty andlor pain in passing urine and sometimes urinary retention.

A review of case records for children and women attending a Nigerian hospital between 1973-81 for complications of FGM found that 22% of the 58 cases had urinary retention, and 2 of the 15 adults

complained of a poor urinary flow. Almost all o f the study subjects had suffered type I1 FGM carried out in the first month of life.

Recurrent urinary tract infections.

Damage to the urinary tract may result in recurrent infection. This condition is particularly common in infibulated women, where the normal flow of urine is deflected and the perineum is constantly wet and susceptible to the growth of bacteria. Sometimes the infection spreads to affect the bladder and kidneys.

A study conducted at Khartoum General Hospital in which all women attending the obstetrics and gynaecology clinic between 1962-66 were interviewed and examined, found that 24% of the sample of 4024 women had urinary infections, and the infection was recurrent in 6% of cases. The condition was four times more common in women with type I11 FGM than with type 11, or no FGM.

FEMALE GENITAL MUTILATION

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^H.NDmK

^, .,.,,,.. ^I

In the other large Sudanese study already cited, suffering from the condition. In the other large study recurrent urinary tract infection accounted for 287 of from Sudan, 244 women out of a total of 1031 with a total of 1031 long-term complications associated long term complications of FGM suffered from chronic with FGM. In this study too, those with type I11 were pelvic infection. The rate was more than 7 times higher at greatest risk, with a rate of infection more than four in women with type I11 than in women with type I1 times higher than women with type I1 FGM and about and 42 times higher than in women with type I.

32 times higher than women with type I or without

FGM. Infertility.

Pelvic inflammatory disease can lead to scarring of

Incontinence. the fallopian tubes and infertility. However, the

If damage has been caused to the urethra or rectum contribution of FGM to the high levels of infertility in during mutilation, and especially where the damage Africa is uncertain.

results in a fistula (see Fistulae), the girl will leak urine The review of hospital cases involving complications andfor faeces constantly. Infibulated women may dribble of FGM type I1 in Nigeria found that infertility was the urine constantly as a result of infection under the hood reason for 6 of the 58 women attending the

of scar tissue at the opening of the urinary tract. gynaecological clinic. A 1980 study in Sudan involving 7505 women, the great majority of whom had FGM type 111, found an infertility rate of 2.2%.

Chronic pelvic infection.

Infection from the vulva may spread internally to affect the uterus, fallopian tubes and ovaries, causing pelvic inflammatory disease (PID). The condition is frequently accompanied by an offensive smelling discharge, and may be caused by infection at the time of mutilation, interference in the drainage of urine and vaginal secretions, including menstrual blood, because of scar tissue, or infection of the wound following childbirth. The rate of PID in infibulated women is three times higher than in women who have had the clitoris amputated.

The study at Khartoum General Hospital already cited found that 23% of the 4024 women interviewed and examined suffered from chronic pelvic infection.

The condition was about 3 times more common in women with type I11 FGM than in those with type 11.

In most cases, excision had been performed in childhood. However, in this study unexcised women also had a high rate of chronic pelvic infection, with 6% of the sample of 204 women without FGM

Abscesses.

In cases where the infection is buried under the wound edges or an embedded stitch fails to dissolve, an abscess can form which will usually need to be opened surgically and drained.

The Sudan study involving 3210 women found that 143 of the total sample suffered abscesses. All were in women with type I11 or type I1 FGM, and the condition was more than 8 times more common in those with type 111. Another study from Sudan involving 939 patients attending a Khartoum hospital between 1987-9 for complications of FGM found that 50% presented with vulva1 swelling, which frequently included infected cysts and abscesses, commonly along the line of the scar tissue. By contrast, very low rates for abscesses were found in a 1967 study, also from Sudan and involving a large sample. Of the 3820 women with FGM interviewed and examined at an outpatient gynaecology clinic in Khartoum, only 5

FEMALE GENITAL MUTILATION mmeooK moNnwE woRKms

1 ²⁷ 1

suffered from abscesses, with the rates being about the Keloids.

same for those with type I11 and type I1 FGM. A keloid is an excessive growth of scar tissue which is also abnormally thickened. Many of the ethnic Dermoid cysts. groups who practise FGM are especially susceptible to

These are one of the most commonly reported long- keloid formation. Keloids around the vulva are term complication of all types of FGM. A dermoid cyst disfiguring and psychologically distressing, and they forms as a result of skin tissue becoming embedded in have the effect of shrinking the genital orifice, which the scar. The gland that normally lubricates the skin will may cause problems of its own.

continue to secrete under the scar and form a cyst, or The 1980 study from Sudan in which 7505 women sac, full of cheesy material. The cyst may grow to the were interviewed and clinically examined found 225 size of an orange or even bigger. Dermoid cysts are not a (3%) of the total sample had excessive scars and serious threat to physical health, but they can be keloids. The great majority of the women in this study extremely uncomfortable and distressing. had FGM type I11 which had been performed in their

The frequency of this condition varies considerably childhood. One of the other large studies from Sudan from one report to another. Nineteen of the 103 1 found a similar picture. 3.6%, or 107 of the 3013 women with complications of FGM in the Sudan study women with type I11 FGM suffered keloid scarring. In developed dermoid cysts, with the rate among women contrast, the other large study from Sudan, involving with type I11 FGM being five times higher than the rate 3210 women, found only l l of the 3022 women among women with type 11. In another study from willing to answer questions about complications Sudan involving 3820 women with FGM, 53 suffered suffered from keloids and painful scars - probably from dermoid cysts in the scar tissue. In this study the neuromas, involving trapped nerves.

condition was about six times more common in women

with type I11 FGM than with type 11.463 teenagers with Fistulae.

FGM were also interviewed and examined, and 5 of the A vesico-vaginal (involving the vagina and the 236 with type I11 FGM suffered from dermoid cysts, bladder) or recto-vaginal (involving the vagina and while none of the 227 teenagers with type I FGM was rectum) fistula may develop as a result of injury affected. In the Nigerian study already cited involving 55 during mutilation, or due to de-infibulation or re- children seen in a paediatric clinic with complications infibulation, intercourse, or obstructed labour.

of FGM, 14 were suffering from dermoid cysts. Of 15 Continuous leakage of urine and faeces can plague the young adults seen at the gynaecology clinic for the same woman all her life and turn her into a social outcast.

study, 4 had dermoid cysts. Gishiri cutting (cutting of the vagina), classified as FGM type IV, was responsible for 13% of 1443 cases of

Neuroma. vesico-vaginal fistulae reviewed in a 1983 study in

If the clitoral nerve becomes trapped in scar tissue Nigeria. Here, gishiri cuts were administered for a it may develop into a neuroma, which is a tumour variety of reasons and at different stages of life, and the consisting of a mass of nerve fibres. The whole genital risk of suffering a fistula as a result rose significantly area becomes permanently and unbearably painful to with age. In another Nigerian study analysing hospital

touch. records, one of the 55 children brought to the

FEMALE GENITAL MUTILATION

1 ²⁸ 1 . ,.,.,,..

paediatric clinic with complications of FGM involving HIVIAIDS and other bloodborne diseases.

the amputation of the clitoris suffered a vesico-vaginal The risk of transmission of bloodborne organisms

fistula. such as HIV and hepatitis B and C viruses may be

increased for women with FGM because tearing and Calculus formation. abrasions are more likely during intercourse, or as a

A calculus is a stone that forms abnormally in the body from chemicals that are in high

A study from Sudan tells the story of a young concentration in certain fluids. Calculi may develop

unmarried girl who was unable to menstruate properly as a result of urine or menstrual products getting

as a result of infibulation. As her belly began to swell trapped in the vagina behind the wall of skin

with menstrual blood that could not escape, her family created by infibulation. The only study in the series

believed she was pregnant. Their suspicion was in which calculi are mentioned is from Sudan, and

heightened by the lack of sign of menstruation, and the condition is described as "rare': In this study

they killed her to preserve family honour.

from 1967, two of a sample of 3013 women who had sought medical attention for complications of FGM type I11 were reported to have calculi.

Menstruation Mculties.

result of anal intercourse when the vagina is impossible to penetrate -but this has not been the subject of detailed research. Bloodborne diseases may The opening of the vagina following FGM may be also potentially be transmitted when groups of so small that menstrual blood cannot flow freely and children are simultaneously mutilated with the same may accumulate. Trapped menstrual blood is known as unsterile instrument. As yet, however, there is no haematocolpos. FGM may also result in published evidence that FGM is a major contributor to dysmenorrhoea (painful menstruation).

In the 1983 Sudan study which interviewed a cross- section of 32 10 women, 39 claimed pain during menstruation. 36 of women had FGM type 111, and of these 17 needed surgery to relieve the obstruction.

Severe dysmenorrhoea was reported by 68 of a sample of 105 Somali women who responded to a postal questionnaire, but there was no indication of how many of the respondents had been excised, nor of the type of FGM. Dysmenorrhoea is mentioned in a number of other studies as being a gynaecological complication of FGM, but there is no indication of the frequency.

the spread of these diseases.

Problems in pregnancy and childbirth

Problems in pregnancy and childbirth are common

in women who have undergone type I11 FGM because of the rigidity and obstruction of scar tissue. If a miscarriage occurs the foetus may become trapped in the uterus or the birth canal. During childbirth, tough scar tissue may prevent dilatation of the birth canal and obstruct labour - a condition that is hazardous and potentially fatal for both mother and baby. During prolonged obstructed labour, the mother may suffer

Sexual dysfunction. lacerations, and perhaps fistulae caused by the (see below: Sexual and psychological consequences grinding of the baby's head against the walls of the

of FGM) vagina, as well as severe bleeding. The baby may suffer

I

FEMALE GENITAL MUTllATlON

A HANDBOOK FOR FRoNniNEwoRKEw

I ²⁹ I

brain damage or even die from lack of oxygen. De- Apart from the direct trauma of the event a n d its infibulation is necessary to prevent obstructed labour psychological effects, FGM works at a more subtle level and allow the birth of the baby. If a trained attendant to shape the self-perception and self-esteem of t h e is not present to cut the skin hood, de-infibulation young girl. In the longer term, women may suffer may cause haemorrhage, injury to surrounding tissues, feelings of incompleteness, anxiety, depression, chronic fistulae and infection. Often the woman andlor her irritability, and difficulty in relating to their husbands.

husband demands re-infibulation following childbirth. Many such women suffer in silence, unable to express Repeated operations will weaken the scar tissue, their feelings and fears either because of taboos o r besides which re-infibulation carries the same long- because they do not know how. Unfortunately t o o term risks as the original procedure. Evidence suggests little research has been done o n the psychological that requests for re-infibulation can be reduced by impact of FGM, or its effect on child development, to offering women and their partners psychosexual establish the magnitude of the problems.

counselling on the health implications. Almost all types of FGM involve damage to o r Though there is a marked lack of data giving complete removal of the clitoris, which is the main figures for problems suffered in pregnancy and labour, female sexual organ, equivalent to the penis of the there is frequent mention of obstetric complications in male. The more extreme forms of FGM, which remove the studies. These include the necessity of performing all the external genitalia, leave tough scar tissue in episiotomies (cutting of the perineum to allow

the baby to emerge); tears in the perineum

because an episiotomy was not performed in In Sudan, women interviewed in depth about their sex time; difficulty in performing vaginal lives named the lips, neck, breasts, belly, hips and examinations during labour to monitor thighs as sensitive. All had type Ill FGM, and nine out of progress; difficulty in passing a catheter to ten claimed they had experienced orgasm at some point relieve a full bladder because of the small hole during marriage, ranging from frequently or rarely.

and tough scar tissue; maternal and fetal distress because of prolonged labour; infected

wounds; and sometimes stillbirth and maternal death. place of sensitive organs. Reduced sexual sensitivity, painful intercourse and the fear of pain, may lead to

Psychological and sexual

sexual dysfunction in both partners. Intercourse may

Consequences of FGM

be difficult or even impossible, which may require re- Evidence suggests that FGM is mostly remembered as an

extremely traumatic event that leaves an emotional scar for life. The psychological trauma sufkred by the child subjected to FGM may settle deep in her subconscious mind and lead later to disturbed behaviour. The loss of trust and confidence in cawgivas, such as parents and other M y members, who allow the p d u r e to go ahead and sometimes assist during the operation, is another potentially serious consequence.

opening of the vagina with a knife or razor. However, FGM does not necessarily abolish altogether the possibility of sexual pleasure and orgasm. Some studies suggest that other erotic zones of the body, such as the breasts, may become more sensitized in women with genital mutilation, particularly when the overall sexual experience is pleasurable with a caring partner.

In a 1982 study from Somalia, 70 women and 40